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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THISIPERMIT. EXPIRES 1 YEAR FROM DATE ISSUED Data Issued 27 <br /> (Complete In Triplicate) <br /> Application is hereby made to `the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereinldescribed. This application is made in compliance with San Joaquin <br /> County Ordinance No., 1862 an&` he Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �( 0 �_ CENSUS TRACT <br /> Owner's Name Phone <br /> Address i City <br /> - <br /> Phone License '��: <br /> Contractor's Name AL A- <br /> r <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT I�T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .. ., PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE 'TYPE OF -WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing v <br /> Domestic/p. <br /> ublic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ZH.P. <br /> Type of Pump <br /> ( PUMP REPLACEMENT: / / State Work Done <br /> IPUMP �.REPAIR: ./ / State Work Done l <br /> yyApproximate Depth <br /> fDES-TRUCTION OF WELL: Well Diameter -- <br /> DescribeNMaterial and Procedure <br /> II hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ction. Within FIFTEEN DAYS <br /> , and the State of California pertainiiAg to or regulating well "constru <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> IWELL DRILLERS REPORT of- the':well and notify' them before putting the.-well in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GPOVTING AND A FINAL INSPECTION. , <br /> TITLE <br /> SIGNED i <br /> � P OT PLAN ON REVERSE SIDE) <br /> [ R DEPARTMENT USE ONLY <br /> [PHASE I �� DATE <br /> APPLICATION ACCEPTED BY <br /> 'ADDITIONAL COMMENTS: PHASE /FIN L INS PEC ION <br /> PHASE II SP ION DATE 7� <br /> INSPECTION BY }DATE INSPECTION BY <br /> F <br /> f 1f77 2M <br />